Haematuria and bladder cancer (module 1) Flashcards
visible haematuria may be referred to as
frank or macroscopic haematuria
non-visible heamaturia may be referred to as
microscopic haematuria
non-visible blood in urine is detected by
microscopy or dipstick urinalysis
3 red blood cells per high power microscopic field indicates microscopic haematuria
most common cause of frank haematuria in adults >50
bladder cancer
15-22% of pts with macroscopic haematuria have cancer in the urinary tract
5% of pts with microscopic haematuria have cancer in the urinary tract
haematuria with concurrent UTI
do not rule out bladder cancer just because a UTI is present.
bladder cancer is often associated with infected urine.
does the presence of visible blood indicate more serious pathology than non-visible blood
yes
visible blood increases risk of more serious pathology
heamaturia with pain may indicate:
Dysuria or irritative lower urinary tract symptoms may indicate cystitis
Severe abdominal or pelvic pain may suggest ureteric (or bladder) calculus
haematuria with blood clots
indicates high degree of haematuria and often means significant urological pathology and may need catheter and bladder washout
DDx for haematuria
- carcinoma (bladder, kidney, ureter, prostate)
- infection
- stone
- trauma eg. catheterisation
- renal eg. glomerular disease, polycystic kidney
- benign prostatic hyperplasia
- anticoagulation
- papillary necrosis
- bleeding disorders eg. haemophilia, sickle cell disease
what to look for O/E
Palpable masses
pain (stones)
rectal exam - revealing enlarged prostate (hard and heterogenous may reveal prostate cancer)
weight loss
anaemia
signs of chronic renal failure
essential investigations for haematuria
- cystoscopy
- upper tract investigation (USS +/- IVU or CT urogram)
- urine microscopy culture and sensitivity
- urine cytology (selectively)
more than 90% of bladder cancers are
transitional cell carcinomas
a few of the rest are squamous call carcinomas or adenocarcinomas
male to female ratio of bladder cancer is
male : female
2.5 : 1
risk factors for bladder cancer
age
male sex
smoking
family history
workers in industries exposed to carcinogens
risk factors for bladder cancer
age
male sex
smoking
family history
workers in industries exposed to carcinogens such as beta napthylamine, benzidine a rubber, textile/dye industry including hair dressers, printing and metal
risk of smoking vs. risk of working in high risk industry
risk of working in high risk industries is negligible compared to increased risk with smoking.
gold standard for diagnosis of bladder cancer
- flexible cystoscopy +/- biopsy for histology
- urine cytology - very specific but has low sensitivity (negative result cannot exclude cancer)
pathological classification of transitional cell carcinoma
often multifocal
growth pattern may be papillary, sessile (flat), or carcinoma-in-situ (CIS)
how do high grade tumours behave
more aggressively
faster growth and more likely to spread than lower grade tumours
grading system for bladder cancer
grade 1: well differentiated
grade 2: moderately differentiated
grade 3: poorly differentiated
TNM staging system
how to diagnose carcinoma in situ
by biopsy/transurethral resection
how to treat carcinoma in situ
intravesical immunotherapy - BCG (Bacillus Calmette-Guerin) with subsequent maintenance.
cystectomy if fails to respond to BCG
why do you manage carcinoma situ of the bladder aggressively
high grade high risk form of urothelial cancer (unlike carcinoma in situ of other sites)
even when not showing invasion it is at high tsk of progression and should be aggressively managed
how to treat carcinoma in situ of the bladder when BCG fails
cystectomy
what is intravessical BCG
live attenuated bacillus calmette-guerin
instilled into the bladder and then drained away via catheter
performed weekly for 6 weeks and then mostly for one year
this is a form of immunotherapy and has been shown to decrease recurrence and progression of CIS and other high risk bladder cancers
Ta and T1 bladder cancer define
Ta means the cancer is just in the innermost lining of the bladder
T1 means the cancer has begun growing into the connective tissue beneath the bladder lining
treatment for Ta and T1 bladder cancer
TURBT (transurethral resection of bladder tumour)
Intravesical cytotoxics - using drugs such as mitomycin
intravesical immunotherapy - using drugs such as BCG (bacillus calmette-guerin)
TURBT stands for
transurethral resection of bladder tumour
how to treat muscle invasive bladder cancer
radical cystectomy
radiotherapy
combined treatments: chemotherapy followed by radical cystectomy or vice versa
multi modal therapy
(when you combine chemotherapy/radiotherapy/surgery)
chemotherapy in addition to surgery - (either before surgery (neoadjuvant) or after surgery (adjuvant)) - is usually required.
if radiation is the prime modality, then cutting out as much of the tumour as possible via TURBT followed by concurrent chemo-radiation is the preferred approach
cystectomy pre operative requirements
major surgery
requires thorough cardiovascular and respiratory system evaluation, bowel prep, blood cross-matched and stoma education pre-operatively
cystectomy process
ileal segment is taken from the bowel and an end-to-end anastomosis is then performed to restore bowel continuity. (it’s mesentery is maintained)
this piece of bowel forms an ileal conduit and stoma.
both ureters are anastomosed to the piece of resected ileum to form the stoma.
how to treat metastatic disease
systemic chemotherapy
palliative radiotherapy - to relieve symptoms and improve quality of life
palliative surgery - radical cystectomy and urinary diversion
clinical presentation of renal cell carcinoma
often late presentation
triad of haematuria, flank pain and abdominal mass. usually asymptomatic
often detected as incidental finding during USS/CT abdo for other indications
risk factors for renal cell carcinoma
smoking
family Hx
known kidney disorders requiring dialysis
treatment for renal cell carcinoma
resistant to chemotherapy and radiotherapy
new drugs which target angiogenesis (eg. sutinib and sorafenib) are becoming available
treat with nephrectomy (partial or radical)
neoadjuvant vs. adjuvant
neoadjuvant = before surgery
adjuvant = after surgery
when should haematuria be investigated
it is a symptom of cancer and should always be investigated
in adults >50 bladder cancer is the most common cause
what percentage of patients with frank haematuria who are investigated will be found to have urinary tract cancer
1/4
(25%)
what should you do for patients with frank haematuria
refer to urologist for cytoscopy
